Pharmacy Department Orientation June 26, 2015 Brittany N. White, PharmD, BCPS Pharmacy Ext. 7238
Main Pharmacy Department Located on the 6 th floor Open 24 hours a day 7 days a week Children s Located on 3 rd floor of main campus Open 7am 10pm daily after hours served by main pharmacy East Located on East campus Open 7am 4pm 5 days weekly after hours served by main campus North Located on North campus Open 7am 3pm 5 days weekly after hours served by main campus Bledsoe Located on Bledsoe campus (Central Time Zone) Open 7am 3pm 5 days weekly after hours served by main campus
General Information UptoDate, MicroMedex located on the intranet Drug side effects, dosing, indications, guidelines Therapeutic Substitutions Claforan to Rocephin Allegra to Claritin Zantac to Pepcid Prilosec, Aciphex, Nexium, Prevacid to Protonix Aranesp to Procrit Imipenem, Doripenem to Merrem Fragmin to Lovenox Renal Dosing
Pharmacy Clinical Services Internal Medicine Critical Care Infectious Diseases Anticoagulation Nutrition Emergency Medicine Pharmacokinetics Drug information
Pharmacokinetics Service Pharmacy doses all Vancomycin Vancomycin dosing 20mg/kg loading dose, then 15mg/kg IV q8-12h Vancomycin troughs-caution interpretation of reported levels Once daily aminoglycoside dosing 5mg/kg 7mg/kg Random level 10 hours post dose Service available 7 days per week in adults
Antibiotic Stewardship Program Cyle White, PharmD, BCPS Pharmacist ext. 5063, Emergin messenger Reviews antibiotic orders on a daily basis for adult patients Leaves suggestions on chart to streamline therapy, make dosages adjustments for better efficacy, stop unnecessary antibiotics
Antibiotic Stewardship Prevent adverse events Examples Clostridium difficile Line-related infections Decrease resistance Examples VRE MDR organisms (GN) Decrease cost
Methods Antibiotic lists Tigecycline, Zyvox,Daptomycin, Micafungin, Voriconazole Antibiotics >11 days 2 or more Abx Vancomycin Fluconazole >3 days Antibiotic recommendations leave notes where appropriate suggests streamlining and discontinuation where appropriate Stop Orders Automatic 7 day stop dates in pharmacy system for abx Evaluate patients chart and place stop orders requesting MD to indicate whether abx needs to be ctd and requests their signature IV-to-PO List of patients receiving IV abx where PO available Automatic switch to PO when pt meets criteria
TPN Available 7 days a week for adult patients Write Consult Nutrition Support Service Consults must be received by 2pm to be started that day Do not order TPN to start after 2pm Not a stat/urgent therapy Enteral feeding ALWAYS preferred If can take sips/clears TPN not indicated If oral intake anticipated within 7 days, TPN not indicated NG/Dobhoff/PEG always preferred Reduced incidence line infections Reduced risk gut atrophy
Pharmacy Anticoagulation Service Pharmacy Anticoagulation Service started October 2010 Reviews coumadin patients for an INR at least every 3 days Reviews supra-therapeutic INRs Reviews LMWH patients that are obese or under weight for appropriate dose Available to dose and follow warfarin To Consult write Pharmacy Anticoagulation Service to Dose and Follow New ACCP guidelines require bridging therapy for 5 days when warfarin started except for a-fib
Adverse Drug Reactions An adverse drug reaction is any unintended, undesirable, and unexpected effect of a prescribed medication or medication error that requires discontinuing a medication or modifying the dose. 4th-6th leading cause of death Over 100,000 deaths occur annually due to ADRs
Adverse Drug Reactions Reasons to Report Postmarketing Surveillance Manufacturing Errors Mandated by JCAHO How to Report Write notify pharmacy of reaction with
Occurrence Reporting An Occurrence is any event that involves potential or actual harm to a patient or visitor or lost/damaged property. Mandatory to report Non-punitive Anonymous State the facts to avoid miscommunication
DO NOT USE ABBREVIATIONS Dangerous Abbreviation MgSO 4 can be misinterpreted as morphine sulfate MSO 4 can be misinterpreted as magnesium sulfate Instead Write Instead write magnesium sulfate Instead write morphine sulfate µg can be mistaken for mg Instead write micrograms or mcg U can be misread as a zero (0) or a (4) IU can be misread as IV or 10 Q.D. can be misread as QID or QOD QOD can be misread as QID or QD Instead write out units Instead write out international units Instead write out daily Instead write out every other day A zero was not used prior to a decimal dose (i.e.,.25units) never leave a naked zero Instead always use a leading zero with a decimal (i.e., 0.25 units) A zero was used after a decimal (i.e., 2.0 units could be interpreted as 20 units Instead never use a trailing zero with decimals (i.e., 2 units)
Order Sheets How do I find the Zyvox Order Sheet? Go to the Intranet Go to Order sets Select Pharmacy Select Linezolid/Zyvox Order Sheet #4026 Select File then print How do I find the Renal Protection Protocol Order Sheet? Go to the Intranet Go to the Order sets Select Radiology Select Renal Protection Protocol #10015 Select file then print
How to Write a Medication Order All medication orders should be printed/entered through CPOE They require: A drug name A dose A route A frequency An indication is required for all prn medications A signature with printed name/pager number/6-digit ID number
Writing PRN Medications All PRN medications MUST have an indication written as part of the order eg, Labetalol 20 mg IV every hour prn SBP > 160 eg, Morphine 2 mg IV Q 4 hrs prn pain not relieved by Percocet
Writing Orders Tennessee state law requires all medication orders be printed Please legibly for others to read All prn orders MUST have an indications Safer to include indications on all medications Sign your name then print with 6-digit ID/use stamp
11 Rules for Preventing Never use U for units Medication Errors Never use chemical names Never abbreviate drug names - MSO4 Never abbreviate once daily as QD may be read as right eye Never abbreviate Q.D. may be read as QID Never use µg, write out mcg
11 Rules for Preventing Medication Errors Never leave a decimal point naked, such as.5mg - write 0.5mg Never add a trailing 0, such as 2.0mg - write 2mg Always use the metric system Include indications with each order Specify exact dosage strength rather than dosage form
Writing Pain Medications Many orders written as a range example: Morphine 1-2mg IV Q4-6h Range orders not appropriate Tie to pain scale Need to specify for what Nursing will start with lowest dose Will be entered by pharmacy with shortest frequency Exp) q4-6hrs will be entered onto MAR as q4hrs
Pharmacy Ext: 7328, 7327
Pharmacy Department Orientation June 26, 2015 Brittany N. White, PharmD, BCPS Pharmacy Ext. 7238